Mortal Choices

Matters of Life and Death: Perspectives on Public Health, Molecular Biology, Cancer and the Prospects for the Human Race. John Cairns. 257 pp. Princeton University Press, 1997. $29.95.

John Cairns's thoughtful and informative book covers a topic of universal interest: public health and mortality. It consists of independent essays on the history of mortality, the emergence of molecular biology and the epidemiology of cancer, among other subjects. Yet the essays are carefully connected to achieve a clear, unified presentation. The style also allows the author, a basic researcher for many years who finished his career at the Harvard School of Public Health, to comment wryly and pose challenging questions: What should our national and global goals regarding infectious diseases and cancer be? Should we increase our efforts to find cures? Are there alternative strategies for preventing, or at least reducing, the incidence of major diseases? And what are the real costs for such efforts?

Cairns's history of mortality is enlightening. From ancient records, he demonstrates that in the past large cities had amazingly high mortality rates. In 1st century Rome, 50 percent of all children died by the age of 10. Although the inhabitants had a high birth rate, the city's population was maintained only by continued influx from the countryside. It was not until the 19th century that this pattern became altered as common efforts for public health led to removal of waste and to better protection of water supplies. A further decline in early mortality emerged in this century with the widespread use of vaccines and antibiotics.

The most significant conclusion from this book is that prevention is better than cure. Cairns carefully documents declines in early mortality from infectious diseases in the 17th and 18th centuries. The improvement in public health came not from medical miracles but from an emerging perception of how improved sanitation correlated with health. This began even before microbiology had become established and could identify specific causative agents for different infectious diseases. This is significant in that it shows we can improve our general health without understanding the mechanism of a particular disease.

In an age in which our attention is focused on cures for AIDS and cancer, the author carefully details how prevention is the more rational strategy. Although cancer is most simply viewed as the result of a mutation in DNA for which some medical treatment must be found, we are given a review of cancer epidemiology that emphasizes how some cancers are caused by environmental carcinogens (preventable by controlling their dispersal) and how other cancers are caused by infectious viruses (preventable by vaccination). Compared to the high cost for treatment of individuals in a hospital, prevention appears an obvious better choice.

However, Cairns suggests that advanced nations are not politically strong—or wise—enough for policies that might impinge on the average person's lifestyle or sense of freedom. Preventive measures have specific costs in raised taxes or inconvenience on every person but only benefit a subset of the population. On the other hand, a medical cure specifically benefits that individual who actually needs it (as long as someone else can pay for it) and thereby appears to be the easier solution.—Thomas Traut, Biochemistry & Biophysics, University of North Carolina, Chapel Hill